What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

Establish rapport and develop treatment goals.

Acknowledge the client's actions, and generate alternative behaviors.

Explore how thoughts and feeling about this client may adversely impact nursing care.

Attempt to find alternative placement.

Answer and Explanation

The Correct Answer is A

a. Establish rapport and develop treatment goals: During the orientation phase, the primary focus is on building trust and rapport with the client. Establishing rapport and developing treatment goals are essential to creating a therapeutic alliance and setting the stage for effective treatment.
b. Acknowledge the client's actions, and generate alternative behaviours: This action is more appropriate during the working phase, where the nurse and client work on behavior change and coping strategies.
c. Explore how thoughts and feelings about this client may adversely impact nursing care: This is part of the nurse's self-reflection and supervision but is not the priority during the orientation phase.
d. Attempt to find alternative placement: This may be considered if the current setting is unsuitable, but it is not the primary focus of the orientation phase.

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Correct Answer is D

Explanation

a. "I know I can't use physical force anymore, but I can intimidate someone with my words." This indicates that the client still considers using intimidation, which is not a healthy way of managing anger or aggression.
b. "Because my wife seems to be the one to set me off, I've decided never to see her again." Avoiding a trigger rather than managing the response to it does not indicate progress in anger and aggression management.
c. "It's bad to feel as angry as I feel. I'm working on eliminating this evil feeling completely." Viewing anger as entirely negative and trying to eliminate it rather than managing it constructively does not show effective anger management.
d. "I realize I have a problem expressing my anger appropriately." This is correct because recognizing and admitting the problem is a critical first step toward making meaningful changes in managing anger and aggression.

A. glucose intolerance resulting in hypoglycemia. B. endocrine imbalance causing amenorrhea. C. decreased metabolism causing cold intolerance. D. cardiac dysrhythmia resulting in cardiac arrest.

Correct Answer is D

Explanation

a. Hypoglycaemia can occur, but it is not as immediately life-threatening as cardiac dysrhythmia.
b. Endocrine imbalance and amenorrhea are significant but not usually immediately life-threatening.
c. Cold intolerance due to decreased metabolism is uncomfortable but not immediately life-threatening.
d. Cardiac dysrhythmias are a major health complication of anorexia nervosa due to electrolyte imbalances, particularly hypokalaemia, which can lead to cardiac arrest. This is a life-threatening condition that needs to be monitored closely.

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What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement, made by the client in group therapy, would demonstrate to the nurse that the client has made progress with anger and aggression management?

Correct Answer is D

Explanation

Which major health complication is associated with a client diagnosed with anorexia nervosa, does the nurse assess as a priority?

Correct Answer is D

Explanation

A client who is agitated and assaultive and unable to be verbally de-escalated is on the inpatient unit. The doctor ordered medications for the nurse to administer to the client. Which medication would the nurse question?

A nurse is caring for a schizophrenic client who is exhibiting delusional thinking, visual hallucinations, suicidal ideations, and periods of depression. The nurse would recognize that the client is displaying which category of schizophrenia?

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